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| Section | Weight | Objectives |
|---|---|---|
| Communication skills | 9.17% | - Effective and non-confrontational physician communication - Roles and responsibilities of coders working with CDI departments - Reconciling CDI working DRGs with final coded DRGs - Physician education forms and tools - Verbal versus written physician communication - Roles and responsibilities of CDI specialists - Educational presentations for healthcare departments and administration |
| Impact of reportable diagnoses on quality of care | 8.33% | - Hospital Inpatient Quality Reporting Program - Patient Safety Indicators - Mortality reviews and observed/expected ratios - Hospital Value-Based Purchasing - CDI impact on Hospital Value-Based Purchasing - Coded data elements affecting Patient Safety Indicators - Documentation and code assignment impact on mortality index - Healthcare-associated infections and complication codes - Hospital Readmissions Reduction Program - Quality data from record abstraction and claims data - Hospital-Acquired Condition Reduction Program - 30-day mortality measures |
| Anatomy and physiology, pathophysiology, pharmacology, and medical terminology | 19.17% | - Diagnostic tests as clinical indicators - Diseases and disorders of the nervous system - Alcohol/drug use and alcohol/drug-induced organic brain disorders - HIV infections - Diseases and disorders of the kidney and urinary tract - Diseases and disorders of the digestive system - Clinical indicators and query opportunities by Major Diagnostic Category - Diseases and disorders of the hepatobiliary system - Injuries, poisonings, and toxic effects of drugs - Standard medical abbreviations - Diseases and disorders of the musculoskeletal system - Endocrine, nutritional, and metabolic diseases and disorders - Mental diseases and disorders - Diseases and disorders of the circulatory system - Pharmaceuticals and disease processes - Infectious and parasitic diseases - Diseases and disorders of the skin, subcutaneous tissue, and breast - Diseases and disorders of the respiratory system - Medications as clinical indicators - Myeloproliferative diseases and disorders and poorly differentiated neoplasms - Diseases and disorders of the blood and blood-forming organs and immunological disorders |
| Healthcare facility CDI program analysis | 8.33% | - Basic computer and software application skills - Hospital Value-Based Purchasing measures - Patient Safety Indicators - CDI program forecasting - PEPPER data - Provider response rates - Publicly reported data - CC/MCC capture - Hospital-specific financial data - Severity of illness and risk of mortality - Tracking and trending physician, department, and hospital performance - Physician performance measurement - Case mix index (CMI) - CDI specialist productivity metrics - High-frequency DRGs |
| Professionalism, ethics, and compliance | 9.17% | - DRG compliance initiatives - CDI department goals beyond reimbursement - Medical record confidentiality - Compliance risks indicated by PEPPER - Leading queries - Potential DRG creep |
| Medical record documentation | 19.17% | - Documentation requiring clarification - Situations in which queries are not appropriate - Types of physician queries - Translating clinical indicators into compliant queries - Addressing diagnoses without clinical support - Provider role and diagnosis code assignment - Physician query formats - When a physician query is warranted - ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice - Clinical indicators - Health record elements used for diagnosis and procedure code assignment - Compliant and noncompliant queries |
| Healthcare regulations, reimbursement, and documentation requirements related to the IPPS | 12.5% | - Medicare contractors and their impact on CDI - Medicare Severity Diagnosis Related Groups (MS-DRGs) - Principal diagnosis and medical necessity - Documentation impact on IPPS reimbursement - IPPS and its updates and revisions - Case mix index (CMI) - Coding and billing practices vulnerable to denial - Complication/comorbidity (CC) - Medical staff and clinical staff documentation responsibilities - Major complication/comorbidity (MCC) - Documentation and medical necessity of setting - Inpatient admission criteria and CMS Two-Midnight Rule |
| Official Guidelines for Coding and Reporting | 14.17% | - Present on admission indicators - Secondary diagnosis assignment - Discharge dispositions and transfers - Working DRG assignment for multiple diagnoses - Principal diagnosis assignment - AHA Coding Clinic - Coding guidelines for principal diagnosis selection - Official Guidelines for Coding and Reporting updates - Hospital-acquired conditions |
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NEW QUESTION # 95
A CDI specialist identifies a diagnosis that would change the case from a lower-weight MS-DRG to a higher- weight MS-DRG. The medical record contains no clinical indicators supporting that diagnosis. What is the BEST action?
Answer: B
Explanation:
A query should not be issued solely because a diagnosis would increase reimbursement when the record contains no clinical basis for that diagnosis.
The 2026 ACDIS/AHIMA compliant-query guidance establishes that CDI clarification must be grounded in the patient's clinical record and directed toward ensuring accurate representation of clinical status. The updated guidance supersedes all previous versions and applies across CDI and coding environments.
Financial impact may occur as a consequence of accurate documentation, but it cannot be the clinical rationale for introducing an unsupported condition. A query containing a single unsupported diagnosis would also risk being leading or otherwise noncompliant.
Likewise, a coder cannot provisionally manufacture a diagnosis simply because it would affect the MS-DRG.
Code assignment depends on the documented clinical record and applicable coding conventions.
This principle applies equally in the opposite direction: if clarification could reduce reimbursement but is necessary to correct inaccurate, conflicting, or unsupported documentation, CDI should still pursue clarification. Effective CDI programs protect the integrity of the health record, not a predetermined financial outcome.
CCDS Reference Topics: Ethics; query compliance; clinical support; reimbursement neutrality; documentation integrity.
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NEW QUESTION # 96
A patient undergoes abdominal surgery. Two days later, the physician documents "postoperative anemia." The hemoglobin decreased from 12.4 g/dL preoperatively to 8.2 g/dL, but the record does not state whether the anemia represents an expected postoperative condition, acute blood loss anemia, or a complication of surgery. What should the CDI specialist do?
Answer: B
Explanation:
The appropriate action is to query for clarification. A temporal relationship-anemia occurring after surgery- does not automatically establish that a reportable complication occurred. Likewise, a CDI specialist cannot independently translate a substantial hemoglobin decline into acute posthemorrhagic anemia without provider documentation.
The FY 2026 Official Guidelines state that complication-of-care code assignment depends on provider documentation establishing the relationship between the condition and the care or procedure unless the classification specifically instructs otherwise. They also emphasize that not every condition occurring during or following medical care is a complication.
The query could present the preoperative and postoperative hemoglobin values, estimated blood loss, transfusions, clinical monitoring, and treatment. Appropriate response options might include acute blood loss anemia, expected postoperative anemia, another diagnosis, or clinically unable to determine, depending on the record.
Option A overstates causation. Option B independently diagnoses the patient from laboratory findings. Option D is equally inappropriate because clinically significant postoperative anemia may be reportable.
CCDS Reference Topics: Complications of care; postoperative anemia; clinical indicators; cause-and-effect clarification; compliant querying.
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NEW QUESTION # 97
Which of the following secondary diagnoses has the MOST positive monetary impact on MS-DRG reimbursement?
Answer: A
Explanation:
Among the listed diagnoses, acute diastolic heart failure has the greatest potential MS-DRG impact because ICD-10-CM code I50.31 is classified as an MCC under the FY 2026 CMS MS-DRG system. CMS specifically identifies I50.31 as an MCC, whereas diagnoses classified only as a CC generally produce a lower severity level within DRG families that distinguish no CC/MCC, CC, and MCC cases.
Acute kidney injury, commonly represented by N17.9 when unspecified, is generally a CC rather than an MCC; CMS examples demonstrate N17.9 functioning as a CC in MS-DRG assignment. COPD with acute exacerbation and many delirium diagnoses may also affect severity assignment, but they do not exceed the MCC effect of qualifying acute heart failure in the standard hierarchy represented here.
The wording "monetary impact" must not be interpreted as permission to pursue diagnoses for financial gain.
CDI professionals should query only when clinical indicators justify clarification. Reimbursement is a consequence of accurate documentation and coding, not the clinical justification for creating a diagnosis.
The actual payment impact also depends on the principal diagnosis, existing MCCs, procedures, payer methodology, and final MS-DRG.
CCDS Reference Topics: CC/MCC hierarchy; MS-DRG reimbursement; acute heart failure; compliant CDI practice.
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NEW QUESTION # 98
A hospital had 1,000 inpatient discharges during a reporting period. The sum of the MS-DRG relative weights for those discharges was 1,750. What is the hospital's case mix index (CMI)?
Answer: A
Explanation:
Case mix index is calculated by dividing the total MS-DRG relative weights by the number of discharges:
1,750 ÷ 1,000 = 1.75
Therefore, the hospital's CMI is 1.75.
CMI is an aggregate measure representing the average relative resource intensity of the hospital's inpatient population under the MS-DRG system. A higher CMI generally indicates that the hospital treated cases assigned to DRGs with higher average relative weights.
However, CMI should never be interpreted as a pure measure of clinical quality. It can be affected by patient population, service-line composition, surgical volume, transplant activity, documentation completeness, coding accuracy, changes in grouper methodology, and other factors.
CMS specifically publishes hospital CMI data and uses MS-DRG relative weights in the IPPS payment methodology. CMS also maintains FY 2026 case-mix and relative-weight files as part of the final-rule data package.
For CDI program analysis, unexplained CMI changes should trigger investigation rather than an automatic assumption of poor documentation. Service-line and diagnosis-level analysis usually provides a more meaningful interpretation.
CCDS Reference Topics: Case mix index; relative weights; CDI analytics; MS-DRGs; program performance.
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NEW QUESTION # 99
Which of the following is considered by CMS to be a HAC requiring MS-DRG adjustment if not POA?
Answer: D
Explanation:
CMS specifically includes deep vein thrombosis and pulmonary embolism following certain orthopedic procedures, including total knee replacement and hip replacement, among Hospital-Acquired Conditions subject to the HAC/POA payment provisions. Therefore, option C is correct.
Under the IPPS HAC payment policy, qualifying conditions that were not present on admission may lose their normal CC/MCC effect for MS-DRG assignment when all applicable criteria are met. This makes accurate POA determination essential in CDI and coding.
Pressure ulcers are also part of the HAC framework, but the CMS category historically applies specifically to Stage III and Stage IV pressure ulcers. An unstageable pressure ulcer does not automatically satisfy the Stage III/IV HAC category merely because it is severe or clinically significant. CMS materials distinguish an unstageable ulcer from a documented Stage III or IV ulcer.
Postoperative pneumonia and septic shock are not, by themselves, the specified HAC category represented by the answer choices.
The CCDS blueprint specifically requires candidates to identify CMS-designated HACs and understand the effect of POA assignment on payment.
CCDS Reference Topics: IPPS; Hospital-Acquired Conditions; POA; MS-DRG adjustment.
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NEW QUESTION # 100
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